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N.D. insurers begin autism therapy coverage

GRAND FORKS, N.D.—Almost a year after a coverage mandate for autism therapy failed in the state Senate, North Dakota health insurers are beginning to roll out coverage of their own.

House Bill 1434 would have required insurance companies in the state to provide coverage for applied behavior analysis, a specific treatment often used to address the behavioral symptoms associated with autism and other disorders. Before this year, that therapy went uncovered by insurance plans used by most state residents, causing many parents to pay bills out of pocket—a condition HB 1434 sought to remedy.

However, before the proposal's defeat in the state Senate, major insurers expressed intent to provide coverage of their own accord. Blue Cross Blue Shield of North Dakota—the largest insurer in the state—and Sanford Health Plan both committed to providing coverage for ABA treatment beginning Jan. 1, 2018, and now are rolling out the plans to do so.

Representatives from both companies said Friday, Feb. 9, they have yet to have ABA services billed to them, a status none found surprising given the recent nature of the development. As with any health insurance benefit, customers should call ahead to their provider to see what's covered or touch base with a human resources representative at their place of work.

Kirk Zimmer, executive vice president of Sanford Health Plan, said his organization is providing coverage for the therapy through its large-group and small-group plans, as well as for some customers who access health coverage through Medicaid.

Sanford Health's plans will include annual benefit maximums for ABA treatment applied in tiers to different age groups. ABA is considered to have the greatest possible impact on an individual with autism or other disorders when started at a young age. The Sanford coverage reflects that by extending the most possible coverage to the youngest bracket of children.

"What we did was study maximum benefit plans written into other states, and these are in line with mandated benefits in South Dakota and Iowa," Zimmer said, adding that Sanford wanted to make sure North Dakota's coverage was compatible with the company's benefits found elsewhere in its operating region.

The coverage extended by BCBSND differs from Sanford in that there are no tiers on age group or benefit maximums, said Jacquelyn Walsh, BCBSND vice president of quality assurance. Rather, the insurer provides its coverage based on medical necessity and the individual case of the patient in question, Walsh said.

Tony Piscione, a chief actuary for the company, said coverage for ABA is being picked up by employers on the basis of group plan renewals, which typically follow a 12-month cycle.

Large group plans, those that apply to organizations of 51 people or more, began their cycle on Jan. 1 of this year. Renewals for small groups, those with 50 people or less, will start that yearly cycle on July 1.

As such, Piscione said the full timeline for renewal of North Dakota plans will take 18 months from the start of 2018. In this first month of the rollout, he said BCBS isn't yet sure what to expect in terms of usage across the state.

But providing ABA benefits isn't totally foreign to the state branch of the Blues. Walsh said the company's coverage of federal employees has provided ABA benefits for about a year now, so corporate planners had a ready template on which to mirror the statewide option.

However, the addition of ABA coverage options to the wider pool doesn't necessarily mean that everyone will see the benefit added to their own health insurance plan.

"For certain lines, it's automatically being added as groups renew," Piscione said, "and for other lines of business, the group has the option available if they want to select a plan that has that coverage—so it's really up to the group if they want to add."

That means individual organizations can have leeway in choosing whether they want to pick a plan for employees that includes ABA benefits.

Pisciano didn't know offhand how many employers were in each category, meaning individuals should check to see if their plan will include ABA coverage.

Andrew Haffner covers higher education and general assignment stories for the Grand Forks Herald. He attended the University of Wisconsin in Madison, where he studied journalism, political science and international studies. He previously worked at the Dickinson Press.